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A.

PSYCHIATRIC NURSING HISTORY


I. IDENTIFICATION DATA

Name

Ward No.

Age

Unit No.

Sex

Hospital ID :

Address

DOA

Education

Occupation

Income

Marital Status :
Religion

Nationality

Language Spoken :

II. INFORMANTS
Name & age of informant

:
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Relationship with the patient

Length of study with the patient


:
(State whether information is adequate and reliable)
II. PRESENTING CHIEF COMPLAINTS

Patients version (Record as verbatim, regardless of how bizarre or irrelevant it is)

Informants version
(Write in a chronological order with duration)

III. HISTORY OF PRESENT ILLNESS

Onset (when was the patient last well or asymptomatic)


Mode of onset abrupt, acute, sub acute, insidious Precipitating factors.
Physical
Psychosocial

Development of symptoms & their change in frequency and intensity.


(Expand the signs & symptoms)

Effects of symptoms on
Self
Other mental functions
Biological functions
Social functions
Interpersonal relations
Law
Suicidal ideations present/ absent

Negative History

Treatment History

Informants Version

V. HISTORY OF PAST ILLNESS

Physical illness (if any) and the treatment


Psychiatric illness
Symptoms, duration
Nature of treatment
Any hospitalization
2

Response to Treatment
Legal problems

VI. FAMILY HISTORY

Family structure (Family pedigree chart)


Family history of similar or other psychiatric illnesses
Current social situation
Communication pattern in the family
Range of affectivity among family members
Cultural & religious values
Social support system
Presence of harmful family behaviours

VII. PERSONAL HISTORY


1. Perinatal History
Childhood history

Attainment of milestone
Age and ease of toilet training
H/o maternal deprivation
Neurotic traits

2. Educational history

Age of beginning and finishing of formal education


Academic achievements
Relationship with peers/teachers
School phobia/non attendance/Truancy
Learning difficulties
Termination of studies with reason

3. Play history

What games were played at what age

Relationship with peers, opposite sex


4. Puberty

Age of menarche, reaction to menarche


Age at appearance of secondary sexual characteristics
Anxiety related to puberty change.

5. Menstrual and obstetrical history


3

Regularity and duration of each cycle


Premenstrual tension & other abnormalities
LMP
No. of children born
Termination of pregnancy

6. Occupational history

Age of starting work, jobs held in chronological order


Reasons for change
Job satisfaction
Present income
Whether job appropriate to the educational level and family
Relationship with authorities/peers/subordinates

7. Sexual & Marital History

Sexual information how acquired


Masturbation/self play (fantasy & activity)
Premarital & extra marital sexual relationships
Sexual practices
Duration of marriage
(self choice without consent/ arranged with consent of parents)
Divorce, separation
Role in marriage
Interpersonal & sexual relationships
Contraceptive measures
Sexual satisfaction
Psychosexual dissatisfactions if any

VIII. PREMORBID PERSONALITY


1. Interpersonal relationship

with family members / friends/workmates/superiors


introvert/extrovert
ease of making & keeping social relations

2. Use of leisure time

Hobbies/interests/intellectual activities
Energetic/sedentary
4

background

3. Predominant mood

optimistic/pessimistic
stable/prone to anxiety
cheerful/sad
reaction to successful events

4. Attitude to self & others

Self-confidence level
Self-criticism
Selfish/thoughtful of others
Self appraisal of abilities
Achievements & failures

5. Attitude to work & responsibility

Decision making
Acceptance of responsibility

6. Religious beliefs & moral attitude

Religious beliefs
Toleration of others standards and beliefs
Conscience
Altruism

7. Habits

Food fads
Alcohol
Tobacco
Drugs
Sleep

8. Fantasy life

Sexual/nonsexual fantasies
Day dreaming-frequency and content

B. MENTAL STATUS EXAMINATION


I. GENERAL APPEARANCE AND BEHAVIOUR
1. General appearance

Physique/body built
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Looks comfortable/uncomfortable
Physical health
Grooming & dressing
Hygiene & self care
Facial expression
Eye to eye contact
2. Attitude towards the examiner
Co-operative / attentive / interested / guarded / defensive / hostile / irritable / aggressive / friendly /
playful / seductive / evasive.
3. Gait & Posture

(Way of standing/sitting/walking etc)


Unsteady gate

4. Rapport
5. Psychomotor activity (PMA)
Increased / decreased / restless / agitated / destructive / self-injurious / aggressive
Abnormal involuntary movements-tics / tremors / akathisia
Catatonic signs rigidity / posturing / stereotypy/ echopraxia / waxy flexibility / negativism /
ambitendency / automatic obedience
6. Hallucinatory behaviour
II. SPEECH

Present/absent
Spontaneous/non spontaneous
Reaction time increased/decreased/normal
Relevant/irrelevant
Coherent/incoherent
Excessively loud/abnormally soft/monotonous
Rate of production low speech/poverty of speech/mutism/rapid speech/pressure of speech
Presence of stuttering / stammering/slurring whispering/muttering/echolalia/neologism (Give
samples of patients speech)

III. THOUGHT
Stream of thought
Decreased rate with increased pauses/poverty of thought/thought block
Form of thought

Loosening of association / flight of ideas / circumstantiality / neologism / word salad /


tangentiality.
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Content of thought

Any preoccupations
Obsessions
Phobias
Overvalued ideas and delusions of
persecution/reference/grandeur/love/jealousy/guilt/nihilism/somatic or
hypochondriac/worthlessness/helplessness/hopelessness/suicidal ideations
Delusion of control, thought insertion/thought withdrawal / thought broad casting

IV. MOOD AND AFFECT


Mood subjective
Objective
(euthymic / dysphoric / depressed / expansive / euphoric / elated /
anxious / fearful / irritable)
Affect Appropriate / inappropriate
reactivity present / reactivity absent
blunted / flat affect / labile affect.
V. PERCEPTION

Illusions and misinterpretations


Hallucinations
Sensory modality
Prominence (clarity & intensity)
Diurnal patterns
Content of hallucination
Response of hallucination
Insight of hallucination
Mood congruent/mood incongruent
Somatic passivity phenomenon

VI. COGNITIVE FUNCTIONS (HIGHER MENTAL FUNCTIONS)


1. Consciousness conscious / confused / somnolence / clouding
Disoriented / delirious / stuporous / comatose
2. Attention
Digit forward tests
Digit backward test
3. Concentration

Serial subtraction tests (100-7, 40-3)


Counting backwards from 20
Enumerating days of weeks and names of months in reverse order
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exalted /

4. Orientation

To time
To place
To person

5. Memory

Immediate retention & recall (Same as the digit span test to assess attention)
Recent memory (Ask how did the patient come to the hospital/what he ate for dinner the day
before or for breakfast / Give an address to be memorized & ask him to recall 15 min. later at
the end of the interview)
Remote memory (Ask for date and place of marriage, name & birthday of children, year of
passing S.S.L.C. examination etc.)

6. Intelligence

Arithmetic ability (Give simple tests of calculation)


Comprehension (Give sample tests for reading and writing)
General fund of information (ask questions to test general knowledge.
Consider patients educational & socio cultural background)
Vocabulary (ask the patient to name the objects seen in the room, parts of objects, generate
words beginning with a particular letter)
Abstract thinking (Test the patients concept formation by
Proverb test at least 3 proverbs should be presented and ask the patient to tell the
meaning.
Ask to tell similarities and differences between paired, familiar objects. Eg: table,
chair / banana, orange /eye, ear etc.

7. Judgment

Personal judgment (Ask about his/her personal expectations, plans and attitudes & assess
whether these are realistic)
Test judgment (ask for course of action in imaginary test situations fire test, letter test)
Social judgment (assess patients interaction patterns with other individuals & other
interviewer)

8. Insight

Completely denies the problem (absent insight)


Attributes to physical causes.
Aware of abnormal behaviour
Understands reality of the problem but not taking the responsibility.
Recognizes personal responsibility and need for taking medications.

C. PHYSICAL EXAMINATION
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D. INVESTIGATIONS
DIAGNOSTIC FORMULATION
1ST
PROVISIONAL DIAGNOSIS
NURSING DIAGNOSES

M.O.S.C. COLLEGE OF NURSING


FORMAT FOR PROCESS RECORDING
Identification Data
Name of the Patient :

Ward

Age

Unit

Sex

Hosp No.:

Address

DOA

Diagnosis:
Language spoken

Session No

Date

Time

Physical description of setting:


Goals:
(1)
(2)
Nurse/student
Verbatim

Nonverbal
responses

Patient
Verbatim

Feelings of the
nurses/student
Nonverbal
responses

Inference

Evaluation
Issues / concerns identified
Themes
:
Effectiveness of interaction in relation to goals:
Plan for follow up interaction
:
Signature of the nurse/student

Signature of the Supervisor

M.O.S.C. COLLEGE OF NURSING

Mental Health Nursing


Format for Psychiatric Nursing care study
1. Identification data
2. Informants
3. Presenting Chief Complaints
Patients version
Informants version
4. History of present illness
5. History of past illness
Medical illness
Psychiatric illness
6. Family History
7. Personal History
8. Mental status Examination
General appearance & behaviour

Speech

Thought

Mood & affect

Perception

Cognitive functions
9. Physical Examination
10. Investigations
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11. Formulation & Diagnosis


12. Etiology of the disorder (Comparative study with patient)
13. Signs & Symptoms (Psychopathology)
Psychosocial Therapies
14. Nursing Management (Nursing care plan)
15. Management Pharmacological Management (attached drug file)
- Psycho social therapies
16. Process recording
17. Rehabilitation programme
18. Discharge Plan
19. Conclusion
20. Bibliography

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